Plasma and Cryoprecipitate

Plasma Components

Plasma is administered to increase the level of coagulation factors in patients with single or multiple coagulation factor abnormalities when specific therapy is unavailable. The INR, aPTT and fibrinogen should be used to monitor the patient with a clotting disorder and repeated following plasma transfusion. If the aPTT is less than 45 seconds or the INR is less than 1.8, plasma transfusion is rarely indicated.

Content: The volume is 250-350 mL/adult unit and 100-120 mL/ pediatric unit. Plasma contains citrate and all coagulation proteins.

Dose: Adult and child: 10-20 mL/kg

Expected Result: Each 10-20 ml/kg dose will decrease the INR when it is greater than 1.8. Plasma transfusions will not substantially correct an INR in the 1.3 - 1.7 range. We recommend plasma transfusions for INR greater than or equal to 1.8.

CAUTION
Plasma requires 20-30 minutes to thaw.

CAUTION
Plasma is issued according to the patient’s blood type.

STOP
Do not transfuse plasma for its colloidal properties or volume expansion.

Indications for Plasma Transfusion

1. Coagulopathy: 

a. with aPTT greater than 1.5 times the mean aPTT (45 seconds)

OR

b. INR greater than 1.8 times the mean PT

AND

  • Active bleeding or
  • Prophylaxis prior to surgery or an invasive procedure

CAUTION
Transfusion of plasma is rarely indicated for prophylaxis when the aPTT or INR is less than the guide above. The potential benefit of transfusing plasma to attempt to correct coagulation studies should be weighed against the risks of transfusion, the expected risk of bleeding with the planned procedure, the urgency of the procedure, and the etiology of the abnormal coagulation study. Plasma should not be transfused merely to correct an abnormal laboratory result.

2. Plasma is effective for emergency reversal of Warfarin therapy. This is required for bleeding patients and/or for those who require emergency surgery. If time permits, Vitamin K can be used to normalize INR in 12-24 hours. Repeat INR after transfusion.
3. Massive blood loss. See Massive Transfusion Protocol section.
4. Single coagulation factor deficiency with active bleeding or as prophylaxis prior to surgery or invasive procedure, when specific factor concentrates are unavailable.

STOP 
Plasma should NOT be used for the following single factor deficiencies: Factor VII, VIII, IX, XIII, von Willebrand factor, and fibrinogen.

5. Plasma exchange for TTP or hemolytic uremic syndrome (HUS)
6. Priming of extracorporeal circuit (e.g., bypass, ECMO, apheresis)

Coagulation Factor Deficiencies and Factor Half-Lives

Factor Deficiency Level Required for Surgical Hemostasis Factor
Half-life
Fibrinogen 100 mg/dL 72-120 hours
Prothrombin 10-40% 72 hours
Factor V 10-30% 12-36 hours
Factor VII 10-25% 4-7 hours
Factor VIII
  • Major Surgery, Bleeding: 80-100%
  • Postoperative: 30-50%
  • Minor Bleed: 30-50%
8-12 hours
Factor IX
  • Major Surgery, Bleeding: 50-80%
  • Postoperative: 40%
  • Minor Bleed: 30-50%
18-24 hours
Factor X 10-40% 24-48 hours
Factor XI 15-50% 40-84 hours
Factor XII 0% 48-52 hours
Factor XIII 5-50% 9-12 days
Reference: Van Cott, Laposata. Coagulation, Fibrinolysis, Hypercoagulation. Clin Diag management by Lab Methods 20th ed, Henry, JB, ed. NY: W B Saunders, 2001: 642-59.

Cryoprecipitate Components

Cryoprecipitated Antihemophilic Factor (AHF) (cryoprecipitate) contains fibrinogen, Factor VIII, von Willebrand Factor and Factor XIII.

Content 
(one unit):
150-250 mg of fibrinogen
40-70% von Willebrand Factor
80-120 units Factor VIII and
20-30% Factor XIII
Volume: Approximately 5-20 mL per unit
Storage: A unit of thawed cryo must be maintained at room temperature and fully transfused within 4 hours of release from the Blood Bank
Dose: Adult and child:  One unit of cryo per 10 kg body weight.  Adult units are pre-packaged pools of five.
Expected Result: Adult: Each unit will increase fibrinogen by approximately 7 to 10 mg/dL.
Child: Each unit will increase fibrinogen by approximately 6 to 10 mg/dL. 

Indications for Cryoprecipitate Transfusion

1. Hypofibrinogenemia. Fibrinogen levels greater than 100 mg/dL are generally considered adequate for hemostasis. When the fibrinogen level is between 100 to 150 mg/dL, cryo should be considered for the following: 

a. Active bleeding

b. Consumptive coagulopathy

c. Prolonged cardiopulmonary bypass or ECMO, when temporary fibrinogen dysfunction is suspected

d. Newborns at significant risk for intracranial hemorrhage

e. Factor XIII deficiency

f. Patients with von Willebrand’s disease who are:

    • bleeding
    • unresponsive to desmopressin (DDAVP)
    • in need prophylactically prior to surgery
The use of DDAVP is preferred to cryo, especially for patients with mild to moderate von Willebrand’s disease (but not in patients with Type IIb von Willebrand’s disease for whom DDAVP may cause platelet aggregates and thrombocytopenia). Humate, a factor concentrate rich in VWF and treated with a viral inactivation step, is preferred to cryo due to Humate’s decreased infectious risk.

2. Fibrin surgical adhesive: A single unit of cryo is available for surgical use. However, commercial fibrin sealants available from the pharmacy are preferred because they have been treated with a viral inactivation step.